• Infection and inflammation of the bile ducts
• Bile ducts carry bile from the liver to the gallbladder and intestine
• Usually caused by obstruction or stasis often due to gallstones or malignancy.

– Bacteria from the intestines enter bile ducts due to blockage.
– Common bacteria: Klebsiella spp., Escherichia coli, Enterobacter spp., enterococci, streptococci.

– Gallstones
– Tumors (pancreatic, cholangiocarcinoma, ampullary, hepatic)
– Strictures or stenosis of bile ducts
– Choledochocele (cyst or diverticulum)
– AIDS cholangiopathy
– Parasitic infections (roundworm, liver fluke)

– ERCP (Endoscopic Retrograde Cholangiopancreatography) can cause ascending cholangitis due to manipulation of the biliary tract.

• Gallstones
• Previous biliary tract surgery or biliary stents
• Biliary strictures
• Tumors in the biliary system
• Parasitic infections
• Medical procedures involving biliary tract manipulation (e.g., ERCP)

• Blockage Allows Bacterial Growth: Bile duct blockage permits bacterial growth and ascent.
• Bacterial Invasion and Inflammation: Bacteria ascend into bile ducts causing infection and inflammation.
• Inflammatory Response: Inflammatory substances are released damaging bile ducts and tissues.
• Progression and Complications: May lead to sepsis and life-threatening complications if untreated.

• Gallstones and cholecystitis
• Diverticular disease
• Hepatitis (viral, drug-induced)
• Mesenteric ischaemia
• Pancreatitis
• Other causes of septic shock
• Cirrhosis
• Liver failure
• Liver abscess
• Acute appendicitis
• Perforated peptic ulcer
• Pyelonephritis

• Up to 9% of admissions for gallstone disease involve acute cholangitis.
• 1% of patients develop cholangitis after ERCP (Endoscopic Retrograde Cholangiopancreatography).
• Affects males and females equally.
• Median age at presentation: 50-60 years.
• 10-30% of cases are associated with malignant diseases such as bile duct, gallbladder, ampullary, pancreatic, and duodenal tumors.

• Charcot’s Triad:
– Fever
– Right upper quadrant abdominal pain
– Jaundice
• Reynolds’ Pentad (indicating severe cholangitis):
– Hypotension
– Altered mental status
– Organ dysfunction

• Chills
• Rigors (shivering)
• Generalized malaise
• Nausea and vomiting

• Fever
• Right upper quadrant tenderness
• Jaundice
• Mental status changes
• Hypotension
• Tachycardia

• Mild (Grade I)
• Moderate (Grade II)
• Severe (Grade III) involving multiple organ systems

• Poorly localized abdominal pain is common in elderly patients.

Diagnostic criteria:
• Previous biliary disorder
• Fever and/or chills
• Jaundice
• Abdominal pain
Laboratory findings:
• Elevated leukocyte count
• Positivity for C-reactive protein
• Elevated liver enzymes

Two of the following present:
• Abnormal WBC count
• Fever > 39°C
• Age ≥ 75
• Bilirubin ≥ 5 mg/dL
• Hypoalbuminemia

• Untreated biliary stones.

• Full blood count (FBC): Elevated white blood cell count with neutrophil predominance
• Liver function tests (LFTs): Cholestatic pattern with elevated ALP, GGT, and conjugated bilirubin
• Inflammatory markers: Elevated ESR and CRP
• Kidney function tests and electrolytes
• Blood cultures: To detect infection and guide antibiotic therapy
• Amylase: May indicate lower common bile duct involvement
• Bile or stent cultures: If stent removed during ERCP

• Endoscopic Retrograde Cholangiopancreatography (ERCP): Gold standard for diagnosis and therapy
• Magnetic Resonance Cholangiopancreatography (MRCP): Used when US or CT are inconclusive
• Endoscopic Ultrasonography (EUS): Alternative when MRCP is not feasible
• Abdominal Ultrasound (US): Examines bile duct dilation and/or stones
• Abdominal CT: Used when US is normal to detect bile duct dilation and/or strictures

• Allows direct visualization of the biliary system
• Serves as a therapeutic procedure for biliary drainage

• Used when US or CT results are inconclusive
• Useful when EUS is not feasible

• Considered when MRCP is not feasible
• Applicable in cases with normal liver tests or high risk of complications from ERCP (e.g., during pregnancy)
• Can be therapeutic

• Bile duct dilation
• Presence of stones

• Fluid resuscitation and correction of imbalances
• Broad-spectrum antibiotics targeting anaerobes and Gram-negative organisms (administered after blood cultures)
• Supportive care: Monitoring and managing coagulopathy

• Endoscopic procedures (ERCP) for biliary decompression
• Surgical intervention if necessary

• Staged into I, II, III based on clinical criteria
• Emergency drainage indicated for severe cases (Stage III) with organ failure, shock, or DIC

• Stage I: Antibiotics, drainage if needed
• Stage II: Early drainage, surgery if required
• Stage III: Treatment of organ failure, drainage, and definitive treatment

• It helps prevent recurrence due to the high risk associated with gallstones

• It can cause life-threatening organ failure, shock, organ injuries, and DIC

• Monitoring for septic shock and organ dysfunction
• ERCP within 24-48 hours for biliary drainage
• Alternatives include EUS-guided, percutaneous, or surgical drainage if ERCP is not feasible

– Favorable with early intervention
– Early endoscopic drainage after stabilization improves outcomes

– Sepsis
– Liver abscess
– Bile duct strictures

– Severity of the condition
– Underlying cause (e.g., infection, obstruction)
– Presence of complications (e.g., sepsis, liver abscess)

– Varies from 17% to 40% based on age and underlying medical conditions

– No response to conservative therapy
– Underlying malignancy

– Hypoalbuminemia
– Prolonged prothrombin time (INR > 1.5)
– Hyperbilirubinemia
– High fever
– Leukocytosis
– Advanced age
– Low blood pressure
– High CRP (C-reactive protein)
– Prolonged antibiotic therapy

– Sepsis
– Liver abscess
– Bile duct strictures
– Pancreatitis
– Organ failure
– Chronic complications: recurrent cholangitis, chronic cholangitis, biliary cirrhosis

– Liver abscesses
– Liver failure
– Bacteremia
– Gram-negative sepsis

– Intra-abdominal or percutaneous bleeding
– Sepsis
– Fistulae
– Bile leakage

– Infected bile reflux
– Sepsis

– Septic shock
– Acute kidney injury
– Multi-organ dysfunction